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New Studies Confirm Safety of Home Birth With Midwives in the U.S.

In today’s peer-reviewed Journal of Midwifery & Women’s Health (JMWH), a landmark study** confirms that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies.

This study, which examines nearly 17,000 courses of midwife-led care, is the largest analysis of planned home birth in the U.S. ever published.

The results of this study, and those of its companion article about the development of the MANA Stats registry, confirm the safety and overwhelmingly positive health benefits for low-risk mothers and babies who choose to birth at home with a midwife. At every step of the way, midwives are providing excellent care. This study enables families, providers and policymakers to have a transparent look at the risks and benefits of planned home birth as well as the health benefits of normal physiologic birth.

Of particular note is a cesarean rate of 5.2%, a remarkably low rate when compared to the U.S. national average of 31% for full-term pregnancies. When we consider the well-known health consequences of a cesarean -- not to mention the exponentially higher costs -- this study brings a fresh reminder of the benefits of midwife-led care outside of our overburdened hospital system.

Home birth mothers had much lower rates of interventions in labor. While some interventions are necessary for the safety and health of the mother or baby, many are overused, are lacking scientific evidence of benefit, and even carry their own risks. Cautious and judicious use of intervention results in healthier outcomes and easier recovery, and this is an area in which midwives excel. Women who planned a home birth had fewer episiotomies, pitocin for labor augmentation, and epidurals.

Most importantly, their babies were born healthy and safe. Ninety-seven percent of babies were carried to full-term, they weighed an average of eight pounds at birth, and nearly 98% were being breastfed at the six-week postpartum visit with their midwife. Only 1% of babies required transfer to the hospital after birth, most for non-urgent conditions. Babies born to low-risk mothers had no higher risk of death in labor or the first few weeks of life than those in comparable studies of similarly low-risk pregnancies.

Importantly, this study also sheds light on factors that may increase risk. These findings are consistent with other research on pregnancy complications, but the numbers of these pregnancies were low in the MANA Stats dataset, making it impossible to make clear recommendations. This article from Citizens for Midwifery contains important information to share with families who are contemplating their birth options and weighing their individual risks and benefits.

This study is critically important at a time when many deeply-flawed and misleading studies about home birth have been receiving media attention. Previous studies have relied on birth certificate data, which only capture the final place of birth (regardless of where a woman intended to give birth). The MANA Stats dataset is based on the gold standard -- the medical record. As a result, this study provides a much-needed look at the outcomes of women who intended to give birth at home (regardless of whether they ultimately transferred to hospital care). The MANA Stats data reflects not only the outcomes of mothers and babies who birthed at home, but also includes those who transferred to the hospital during a planned home birth, resolving a common concern about home birth data.

This study adds to the large and growing body of research that has found that planned home birth with a midwife is not only safe for babies and mothers with low-risk pregnancies, but results in health and cost benefits that reach far beyond one pregnancy. We invite you to share this news in your communities, and join the conversation on our Facebook page, Twitter, and Pinterest.

Wow... so amazing to read this! I am not only beginning my career training to become a nurse-midwife, but am also a mother of two girls, one whom was born via vbac. It is so inspiring to see these numbers being published. Fear rules us as a society, especially in regards to labor and birth. It is my goal to help relinquish those fears and normalize child birth. This is definitely a step in the right direction! Thank you so much for sharing this!

A study paid for and published by a large Midwives group? "among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies." So they are able to cherry-pick their patients as well. Any mother above a low-risk threshold wouldn't be cared for by a midwife or be recommended for a home birth. As a result only healthy mothers with healthy babies give birth at home but the hospital has to take all patients regardless of risk. The data is skewed because the hospitals have to take on every high risk birth whereas midwives can opt out.

Seriously!? Midwives are not able to cherry pick because they don't have full exposure in the first place. The hospital holds the giant cherry bowl and parents seeking out homebirths are growing the trees and picking cherries for themselves.

Most healthy parents don't know home birth is an option and those who do rarely consider it because it is "unknown." These stats provide security and hope for people who may have been on the fence. Pregnancy and childbirth should be approached as a normal part of every life, not as a "medical condition."

Let the hospitals take the high risk cases, isn't that what it's there for…when a medical condition is present?

It's true, we can’t make a direct comparison to hospital outcomes (because they include women with different risk factors), but this isn't as much a comparison to hospital care as it is an independent study that stands on its own. We are excited to show that midwives have such low intervention rates and high breastfeeding rates. And, yes, in fact, we do tend to select our clients. We do have guidelines that require our clients to maintain healthy pregnancies and not "risk out" as we call it. This is part of the reason that homebirth is so safe: it's being held by competent, professional, well-trained midwives who know how to keep mothers and babies healthy and safe. Thank you for your comment.

What you call "cherry picking" is actually a risk assessment. Of course home birth midwives are doing a great job in assessing low risk candidates for home birth. This is part of the quality of care we provide. It is our responsibility. It happens in the hospital as well, with family practice physicians and nurse midwives referring high risk pregnancies to their OB colleagues. This is what we call appropriate care.

What MANA then did was take this low risk pool of women and newborns and compared them to low risk people in the hospital. That is the comparison, not low risk to all risk. So the question isn't "is home birth safe", rather "why is hospital birth so risky" for low risk women? Why is the ceserean birth so high amongst low risk women in the hospital? This study, in addition to aiding families to make place of birth decisions, should spur our hospitals to improve the care tey provide.

I have two children and one on the way. My first was born at a birth center and my 2nd was born at home in the water. The plan is to have this 3rd one at home as well. I hope this article spreads throughout the US and sheds positive light on midwives and home births for all of the doubters out there.

Best part about having a home birth was that I was able to crawl into my own bed right after the birth! :)

PermalinkSubmitted by Angelique Chelton (not verified) on January 2014

A follow up comment:

It's great that low-risk women can deliver at home and women who are in higher risk categories can deliver in a hospital where there are caregivers trained to the level of care needed for their medical issues.

This is not 'home' vs 'hospital'. This is a study that supports the fact that low-risk women can deliver safely at home if they so choose without raising their risk of unwanted outcomes.

There's a place for everyone! NOW- let's improve the OVERALL maternity system in the US! :-)

Yahoo! Thank you MANA for the many years it has taken to collect this data. And, thanks very much to Missy Cheney and the wonderful researchers who worked to publish this information in a leading midwifery journal.

Thank you to MANA for collecting these data, and to the researchers for publishing these findings! As we work to incorporate a model of shared decision-making into maternity care in this country, it is essential that women and their care-providers have access to high quality data like this. Decisions about where and with whom to give birth are not always simple, but giving women access to good information to aid in those choices is a huge step in creating a system where all women are able to choose the care and place of birth that is right for them. Looking forward to more information from this rich dataset!

As a home birth mother of two, doula mentor, and childbirth educator, I feel passionately that women and families need to make informed choices based on evidence-based research. This study provides women with the information needed to make decisions regarding the safety of home birth. Thank you, MANA, for your continued dedication toward the midwifery model of care! It works. Every woman deserves to be the recipient of a high level of individualized and respectful care during this incredibly important time in her life. I will be sharing this study far and wide!

PermalinkSubmitted by Margaret Henderson (not verified) on January 2014

The statistics are admirable, and all the success stories sound lovely. But, as I understand the law in North Carolina, an MD is required to be in the building where the midwife is assisting with a birth. If the midwife assists a home birth then brings a laboring woman to the hospital with a problem, she can be arrested so she becomes "a friend" of the woman, no longer her midwife. So the information she should be passing along to the doctors about how the presenting problem developed, I assume, is never transmitted. Please speak about this very real situation in a state such as North Carolina

Margaret, you bring up very important points that may very well impact the ability of a midwife to provide excellent care to clients choosing home birth. Currently, we are not aware of any published studies that look at outcomes and processes of care in states where midwives do not have access to licensure. It may be difficult to conduct such a study if it is unsafe for midwives to contribute data. At the same time, while it may be tempting to assume that some outcomes are worse because of the risks imposed by this system, we have little to no data to support that assumption.

PermalinkSubmitted by Stephanie Zacharda (not verified) on January 2014

As a woman who had two home births, I'm so happy to see a study such as this documented! This is a great resource to all women who are looking at their birth options and wondering what the right path is for them. No longer do us women who chose home birth have to rely on our only our community and experiences, we have MANA to back us up!

PermalinkSubmitted by Treesa Mclean, LM (not verified) on January 2014

It is heartening to see information published about midwifery care, and the real risks and benefits to birthing outside of the hospital. I am especially happy to see the breastfeeding rates. I cannot wait to sit down and read and more fully digest the meaning of this important study.

if you define "reduced cesarean rate" as success then yes, i guess this study shows that. if you define success as "fewer dead babies" however you're 450% more likely to have a dead baby with a homebirth than in a hospital. this is highly disingenuous reporting and analysis of the data. 1.61 per 1000 with home birth low risk vs. 0.38/1000 low risk hospital over the same period.

Speaking of disingenuous reporting and analysis of the data, would you please share with us how you got to 450%? I find that unfortunately, many folks in the last few days have been led astray by misleading numbers floating out there in the web. I would like to examine the real numbers here:

The data in this study might not have had a comparison group, but it was compared with aggregate national data provided by the CDC, our national vital statistic system. If we look at these numbers we will find:

0.41/1000 early neonatal death rate in the MANA study compared to 0.46/1000 early neonatal death rate from national data;
0.35/1000 late neonatal death rate in the MANA study compared to 0.33/1000 late neonatal death rate from national data.
There is no national data on the intrapartum neonatality rate, so we cannot compare that to the MANA data.

Could it be that your math includes ONLY NEONATAL DEATHS? Again, the CDC wonder database does NOT have information on intrapartum fetal deaths, so they are missing a huge chunk of the equation. At the end of the day, you just cannot compare the CDC's neonatal death rate to MANA Stats' intrapartum + neonatal death rate -- that is apples to oranges. And when the data is not available, we must not assume that it was zero..

I would like to suggest that comments like yours are possibly doing a huge disservice to women that need reliable information to make informed choices for their families, after all, isn’t it what this is all about? It’s not a war between care providers and you are hurting women and babies when you make numbers up like this.

My data was from the CDC set based on analysis done by SkeptialOB and I should've noted that. I think the CDC data set makes the most sense compared to out of date studies or studies from other countries (with varying levels of certification and training for midwives). The paper doesn't even give reasons for not using the CDC data.

There are other data sets that do compare one-to-one. For example this study found in breech births a 20/1000 death rate for homebirth while in a hospital setting 0.8/1000. You can find similarly terrifying statistics with VBAC and twins from this data. This study should at least counsel against high risk homebirths, but it glosses over them.

I think women need reliable information to make informed choices for their families. Anyone that prioritizes anything at all over the lives of mother and child, whether that's location, cesarean, or favorite music, is hurting women and babies. I think this study shows that homebirth significantly increases risk of death in all cases, and specifically high risk cases.

There are many reasons that the number being cited - .38/1000 - can only be sourced to a blogger.

The most significant reason is that in the U.S., a full and accurate picture of death rates in the hospital is simply not available. If it were, we would all be citing peer reviewed numbers by an epidemiologist.

The CDC reports only neonatal death rates; they do not report intrapartum deaths (babies who die during labor). For this reason, a convenient U.S. hospital comparison group simply cannot be cobbled together from birth certificate data. This is one very big reason why the researchers didn’t do it. In an attempt to extrapolate a comparison, some are pointing to a letter written by a CNM who assumed that the rate of intrapartum death in the hospital is zero, but that person has subsequently publicly backed off from her assumption. Continuing to cite that erroneous assumption is deliberately misleading and dangerous.

Yet another important piece of the puzzle when using birth certificate data is that birth certificates do not capture where the mother intended to give birth, only where she ultimately did give birth. This does not allow for appropriate comparisons to be made, because we know that not only do unplanned, unattended home births have poorer outcomes than planned, attended home births, we also know that about 10-11% of planned home births transfer to the hospital. The vast majority of these are for pain relief and maternal exhaustion, but some are appropriate transports for true complications that developed in labor. None of these can be properly attributed to the planned place of birth when using birth certificate data, and this matters greatly when examining rare outcomes such as deaths.

We can understand why, in the absence of credible, unbiased, peer-reviewed data, some bloggers would like to make their own back-of-the-envelope calculations, just to give their readers a comparison. So let’s examine that number you cite. First, we have not yet seen any blogger - including the one you cite - replicate the .38/1000 number. Even if it were replicated, the methodology of gathering this number is neither peer reviewed nor published.

This number has many, many limitations, even as a rough estimate. For example, some bloggers are developing their own rates by including only the hospital births that were attended by nurse-midwives. In a hospital setting (or a home birth transfer), care is, quite appropriately, transferred to a OB when needed. This means that looking only at the CNM-attended births excludes all of the outcomes of the births that were transferred to OBs, which would understandably have poorer outcomes. You can’t exclude these outcomes from the hospital group but keep them in the homebirth group.

Also, comparing an early and/or early + late neonatal death rate of 0.38/1000 in the CDC data to an intrapartum + early + late neonatal death rate from the Cheyney et al study is also deliberately misleading.

As we understand it, were the researchers able to make these comparisons to the hospital numbers and still be peer reviewed, they certainly would have. But the reality is, we just don’t have that information. This is why we created MANA Stats - to create valid data based on medical records to give us a more accurate picture. We hope that more researchers will access the data in the future. To learn more, see here.

Finally, the role of the researchers in this publication was to report the findings from the 2004-2009 MANA Stats dataset. It is not the role of the researchers to tell mothers and families what they should and should not do. Ethics dictate that all healthcare providers should respect the autonomy of individuals to make their own informed decisions, and this study provides further information about the risks and benefits of planned home birth so that families can make those decisions with the information available. We respect your opinions regarding what your choice would be, and we acknowledge that those opinions are not universally shared. It may be a gross oversimplification to say that any risk to the life of a mother or child, no matter how miniscule, should always trump the much greater, well-documented risks of the alternatives, including risks to future pregnancies. This is a very personal decision, informed by evidence as well as the individual context of the mother and family, and is not for these researchers to assert.

PermalinkSubmitted by Terry Mackintyre (not verified) on February 2014

Please check out the vital stats data from Oregon released in Sept 2013.
These data report intrapartum and early neonatal death rates in full term women who intended to deliver out of hospital (and subsequently deliver either out of hospital or in hospital) at the start of labor compared with women who intended a hospital birth (thus "higher risk" pregnancies are included in this group) in 2012. The intrapartum death rate in planned out of hospital births was 2 times greater than planned hospital deliveries and the early neonatal death rate for planned out of hospital births was 3 times greater than for planned hospital births. Certainly concerning results.

PermalinkSubmitted by Rachel Hansen, ... (not verified) on January 2014

I am so grateful to see this research finally published, thanks to the hard work of the researchers, the MANA statistics team, and the hundreds of midwives who contributed data. What some call "cherry-picking" is actually the responsible selection of low-risk women as candidates for homebirth. This study confirms that homebirth is a safe choice for low-risk women, with a lower risk of complications such as cesarean and early termination of breastfeeding.

PermalinkSubmitted by Jeff Olejnik MD... (not verified) on February 2014

I have respect for women who choose where they want to give birth and their plans on how they wish to birth. But I am confused with the MANA results and the MANA press statement. The study was expected to have information of over 29,000 deliveries but only has less than 17,000. Apparently only 20-30% of the midwifes responded and all of it was volunteer reporting. MANA released the low intervention statistics years ago and only now release the outcomes data, why? The actual data is suggestive of a low risk of bad outcomes for homebirthers, but they are clearly at higher risk than hospital birth! The press statement doesn't specifically compare the numbers to any hospital rates of bad outcomes and even states there are really no data sources out there to compare to hospital outcomes. Then the press release statement states Homebirth is safe.
Now in the few days since its posting, sites have linked to this press release and Homebirth advocates are cheering and even as going as far to state that Homebirth is safe and there are no increase bad outcomes with Homebirth according to the MANA data. I am ashamed of MANA. The date clearly is comparable to birth center and hospital data, and there is at least double to 5.5 times the risk of death. Homebirth is in America as Homebirth in America does, yet the Homebirth advocates who are looking at the actually data are making excuses about the worse outcomes as they speculate that it is either due to the high risks births that were included, or because they must have been farther away from the hospital than just 5 minutes, or just ignoring the outcomes data and focusing on the low intervention data.
Women attempting Homebirth need this data to make an informed decision. If they are low risk or high risk and know the data and still want to Homebirth then fine. But too many people out there are looking at your press release and saying they knew all along that Homebirth was as safe as hospital birth. You have released a very deceitful press release, that will lead to more poor outcomes from women who thought your data meant it was as safe. I believe it is a large misrepresentation. I hope the sites that are discussing the actual rests continue to spread the word and I hope ACOG puts out an opinion of these results soon.

"The date clearly is comparable to birth center and hospital data, and there is at least double to 5.5 times the risk of death."

Can you please site the source from which you found a 5.5 times risk of death? Are you referring to mother or baby? During pregnancy, birth, or after birth?

If you are referring to death of a baby, hospitals are not keeping (or releasing) their data on intrapartum deaths. Therefor, if you compare MANA data with hospital data, you must exclude the MANA intrapartum fetal death and only look at early and late neonatal death. If you do this, the rates of neonatal death are similar to that of hospital data (per the CDC). You cannot just add the intrapartum deaths from MANA and say that it's a reasonable comparison since the CDC doesn't include deaths of babies who were not born alive.

PermalinkSubmitted by Jeff Olejnik MD... (not verified) on February 2014

Again, the intrapartum death rates are out there. Judith Rooks CNM has commented on them. Doula Dani has already made a nice comparison on her blog site using the Birth Center study and the CDC Vital Statistics records. I am sure MANA is competent enough to find these statistics as well. My question is why did they choose not to directly post them for comparison? Why is there all these posts saying hospitals are not posting their intrapartum death statistics? There are right there in front of every ones faces.

So, my mother had 7 children - in the late 1970's and early to mid-1980's.

She had 5 of those children at home. The last two children were twins. The first of the pair came out fine, the second was breech. He was delivered via c-section at a local hospital in Fairfield, California in 1985.

We were all healthy. None died after birth. If we had this capability in the 1980's, then I think the fear-mongering and attempt to spread paranoia about at home births is just ridiculous. You realize, we managed to populate this earth very well, and long before the advent of modern medicine and hospitals, all through at home deliveries monitored through midwives, right?

Modern medicine has its role, but pregnancy is not a health condition, and women should have the ability to do research on home delivery without your (or other individuals') attempts at instilling irrational fear.

If you disagree, then do so respectfully and provide data, and cite your sources so women can do their own research and not rely on your words alone. When you fail to produce this, you look like someone spreading false information for your own purposes. You should be ashamed.

PermalinkSubmitted by Tina Tsiakalis ... (not verified) on February 2014

The data on intrapartum death reported in the MANA study on home births is not being and can not be compared to intrapartum deaths occurring in hospital because we simply do not have that national data. What the study does provide is data to help families make their own decisions, with intrapartum death rate among low-risk women comparable to that found in several other home birth studies.

PermalinkSubmitted by Frederick Kosta... (not verified) on February 2014

This is an interesting comment. Do you believe that the MANA data is collected form a cohort of home birth where these women are at a 3-4 fold increase in perinatal death compared to the national data? If so, why? As a physician, I am concerned about the reluctance to self-examine. A similar finding in any other medical literature would prompt immediate introspection, safety initiatives, and quality improvement. If this were a medical device, I would expect it to be withdrawn from the market. Clearly, homebirth is a more complex issue but what we need from MANA is an honest representation of their data and an initiative to improve safety without scapegoating or whitewashing.

PermalinkSubmitted by Tina Tsiakalis ... (not verified) on February 2014

No, I don't believe that there is a 3-4 fold risk of perinatal death at home birth because as I said in my comment, we don't have the intrapartum data from hospitals in order to even make an apples to apples comparison. Those who have actually read the Cheyney study can see that the authors compared their outcomes to many other studies on planned home birth and found no differences in intrapartum and neonatal death rates. Several of those studies were done in countries where they DO have hospital comparison groups, and they were no different. We simply don't have the hospital data for intrapartum in this country, and for that reason, there is a huge gap that prevents us from making statements like yours.

PermalinkSubmitted by Elias Kass, ND,... (not verified) on February 2014

Jeff, you bring up interesting ideas about safety. Can safety only be ascertained in relative terms? You seem to be saying that this study can't make any statements about safety because there's no comparable data for hospital births to compare to. On the contrary, safety can exist in absolute terms, especially when it's being used for decision making. Someone may decide that a 1.30/1000 intrapartum fetal death rate is acceptable. Some may decide it is not. It would definitely be helpful to have that information available when you're deciding where to have your baby. Assuming you have to have it somewhere, now you know what it would be at home with a trained midwife, but how can you know what it's going to be in your hospital? Time for the hospitals to step up! Let the hospitals -- individually? by region? by state? -- publish their data, then each setting can challenge the other to better deliver care. In Washington, OB-COAP collected data from hospitals and home birth midwives for the purpose of quality improvement. Why can't each quality improvement organization involve all birth settings?

The press release clearly states that this study looked at low risk pregnancies. "This study adds to the large and growing body of research that has found that planned home birth with a midwife is not only safe for babies and mothers with low-risk pregnancies, but results in health and cost benefits that reach far beyond one pregnancy." Risk assessment is an important part of every midwife's practice, just like a family practice doc who does OB is always assessing if someone needs to go to OB or maternal-fetal medicine, every health provider continually assesses and refers their patients to the appropriate level of care. Each of these studies should help each kind of provider improve their ability to assess risk and offer patients the best options for their particular situation. I have no idea what the situation is like in your region, but it's possible that those best options include home. If you're an OB, some of your patients might eventually decide that they'd like a home birth. If you have relationships with the midwives in your community, whether it's formal or informal, and understand the legislation and infrastructure available to them, then you can honestly guide your patients to make a decision that's right for them.

PermalinkSubmitted by Jeff Olejnik MD... (not verified) on February 2014

I am going to refer to doula Dani's blog where she demonstrates the hospital and birth center intrapartum death rates. Judith Rooks' comment about hospital intrapartum death rates of 0.1-0.3/1000 is referenced there too.

Pointing to someone else's blog, who points to someone else's blog, where no one is actually transparent about where their numbers came from... It seems like there is a whole lot of circular logic going on here, and I'm surprised to see someone with "FACOG" in their credentials participating in this.

My blog is the one referenced above. I did not pull from someone else's blog. I linked to studies and papers were I got the mortality rates. It is actually completely transparent and I have links for exactly where I pulled the information. I, myself, used the Birth Center study, CDC Vital Statistics and in another post, CDC Wonder Database. All links and references are provided. Do you see an error in any of the information I provided?

The intrapartum fetal mortality rate was 0.47/1000 for the Birth Center study..... compared to the intrapartum fetal mortality for the new MANA study which was 1.30/1000. That difference is not small.

Looking at that same study for a comparison of total neonatal mortality rate (early plus late neonatal for both studies)... Birth Center study shows their neonatal mortality rate was 0.40/1000 excluding anomalies. The MANA study shows their neonatal mortality rate was 0.76 excluding anomalies. Almost two times greater risk.

TOTAL MORTALITY RATES (intrapartum plus neonatal):

MANA study = 2.06/1000
Birth Center study = 0.87/1000

A baby born at home with a CPM is 2.4 times more likely to die than baby born with a CNM in a birth center. This means for every 10,000 babies born at home with a CPM, 12 babies will die that would have lived had the mother been under the care of a CNM at a birth center. A part of this increase is because most CABC accredited birth centers will risk women out who are no longer considered low risk. A low risk woman should take proper screening measures to ensure she remains low risk if you want to consider the rates that reflect low risk women only. To look at low risk comparison, we have:

TOTAL MORTALITY RATES for LOW RISK (intrapartum plus neonatal):

MANA study = 1.61/1000
Birth Center study = 0.87/1000

A home birth is then just shy of two times more likely to end in the loss of life of a baby than if the baby were born at a birth center with a CNM. This means for every 10,000 babies born to low risk moms at home with a CPM, 7 babies will die that would have lived had the mother been under the care of a CNM at a birth center. There were well over 10,000 low risk women in the MANA study....

How is this not transparent? I have listed the study where the information comes from and listed the rates, just as I did in my blog post. When I compared to the CDC Vital Statistics, I not only provided the exact source, but shared the exact page, row and column where the information can be found. When I compared to the CDC Wonder Database, I showed my exact search criteria and shared screen shots with the information. It is all spelled out quite nicely and completely transparent.

Danielle, thanks for laying it all out there, but can you explain why you compared the intrapartum fetal mortality rate for the Birth Center study, which had no twins, a handful of surprise breeches (most of which were probably transported to the hospital as soon as they were discovered) and another handful of VBACs because all of these are disallowed in accredited birth centers per AABC’s & CABC’s rules (I read the study)… and compared it to MANA’s intrapartum rate for the group that contained a load of VBACs, breeches and twins that comprised nearly 10% of the total sample? The researchers who wrote the MANA study clearly explained that this is not comparing apples to apples, yet you persist. If you were truly interested in outcomes that may be attributed to place of birth, then you would want to compare cohorts that are as similar as possible in other ways. Leaving the higher-risk births in the MANA sample when they are virtually non-existent in the birth center sample creates tremendous confounders that are not necessarily due to place of birth, but rather to the risks inherent in the risk factors themselves. You wrap it all up by suggesting that these are babies that would have not died if they had been born in a birth center, but you conveniently ignore the fact that these births cannot even happen in CABC-accredited birth centers because they are not allowed. So, um… ?

You also have to understand the concept of statistical significance in order to even be in this conversation. I can see that you’re a big fan of relative risk, but what you’re not acknowledging is that there are tests of statistical significance that researchers run in order to determine whether any difference between two outcomes is real or not. Cheyney & Co. clearly stated that when they looked at the difference in intrapartum death rates between the low-risk MANA sample and the birth center sample, they were “statistically congruent” -- this means that statistically speaking, there was no difference between the two. Anyone who knows how to run tests of significance can do it themselves, the numbers are all right there in the studies. I don’t know what else to say about that, other than that if you DO understand the concept of statistical significance, it seems odd for you to be ignoring it in this discussion.

The last piece that you also seem to be weirdly torturing here is that both the birth center study and the MANA study had nurse-midwives and CPMs/ LMs and other kinds of midwives represented in their studies. Neither of them were exclusive regarding type of midwife; the birth center study included about 20% CPMs/ LMs, and the MANA study included about 15% CNMs. Neither study was about the kind of midwife involved; they were about the location of birth. It’s not helpful to be twisting either of these studies into a CPM versus CNM kind of debate, because your data does not support it.

Midwives doing home births have some interesting conversations that need to be had about some of the outcomes in this MANA study. Mothers need to think carefully about this information too. It seems just a wee bit patriarchal for some of the commenters here to say what decisions mothers should or should not be allowed to make for themselves. But the kind of arguments that you’re trying to make about the data are not even valid.

It's been a while since my college statistics classes - about 10 years since I graduated - I'll leave it up to the experts to say what is considered statistically significant or statistically congruent or whatnot. Women can decide for themselves but they deserve to see some numbers for comparison, since none were included in the study. They referenced other studies but unfortunately did not include any numbers for readers to see. Why didn't they include any numbers? Here is what I am referring to in the study: "The intrapartum fetal death rate among women planning a home birth in our sample was 1.3 per 1000 (95% CI, 0.75-1.84). This observed rate and CI are statistically congruent with rates reported by Johnson and Daviss[4] and Kennare et al[30] but are higher than the intrapartum death rates reported by de Jonge et al,[10] Hutton et al,[12] and Stapleton et al.[14]"

The majority of the births included in the MANA study were by CPMs; majority of the centers included in the Birth Center study were CNM birth centers (80% were CNM centers, 14% were CPM/LM centers, 6% were combo of CNM/CPM/LM). I'll fix what I wrote in my blog to make sure this is clear. Can you point me to where or how you got 15% from the MANA study were CNMs? I'm getting closer to 9%.

I'm not trying to make any decisions for anyone else. I am just trying to make sense of the outcomes by comparing to other studies and papers. I'm not switching anything around to try and make the outcomes look worse than they do. I pulled neonatal mortality rates from the Wonder Database, searching for criteria that matches the MANA study as closely as possible (White women, Singles and twins, 37 weeks and above, Birth weight of 2500 grams or more, Live birth through 27 days, Years 2004-2009; it includes everything else: all ages, all education levels, all marital statuses, etc). Both rates below include lethal anomalies since you can't take them out of the hospital numbers:

Danielle, you ARE trying to obfuscate things by torturing the data and attempting to point to conclusions that have no basis in truth. You and your friends have a clear agenda, and that is to create as much confusion as possible, and to oversimplify and polarize the debate. There is ZERO basis for your statements of “X babies will die that would have lived had they been under the care of a CNM at a birth center.”

Here’s the reality: if a mother has a baby in a breech position, she is not allowed to give birth in an accredited birth center, nor is it likely that she could even have CNM or OB care in the hospital for a vaginal delivery. She will have no other choice but to have a c-section, which has well-documented risks including greater risk of death to herself as well as to future babies.

If a mother had a prior cesarean and wants a vaginal birth in the current pregnancy with all of its benefits, she is not allowed to give birth in an accredited birth center. There are ENTIRE REGIONS OF THE COUNTRY is which she will be denied that choice even in the hospital and be sectioned again, carrying those greater risks of death to herself and future babies. In hospitals where she is “allowed” to have a VBAC, there’s about a 90% chance she’ll end up with another cesarean anyway, compounding her risks and essentially guaranteeing she’ll never have a vaginal birth.

It’s people like you that want to essentialize everything down to one risk and ignore everything else, even when that one risk is statistically no higher at home than anywhere else. The authors of the Cheyney study do not seem to be trying to hide facts here; the data was pretty transparently laid out. It’s this crazy nonsense that you and the other minions from the Skeptical OB blog are trying to spin with your given talking points. Go look at Table 1 in the Cheyney study and do the simple math: 15% of the births were attended by people holding a CNM credential. You claim to be able to slice and dice data flawlessly at the CDC Wonder database, yet can’t look up numbers in published studies and blame Cheyney for not spoonfeeding them to you? Come on.

P.S. Here’s a bonus secret for you: you CAN exclude lethal congenital anomalies from the CDC Wonder tool. It’s a simple checkbox. But you can’t create a comparison group with a similar proportion of Amish & Mennonite folks as the MANA Stats sample in order to make it a fair comparison when leaving them all in. I'll leave it to you to figure out why that matters.

I'm not trying to spin or torture the data. And there is no need to name call. I am no one's "minion." I am a former home birth advocate and one of the reasons I am a *former* home birth advocate is because of the misleading information and attempts to hide the truth from women about the real numbers behind the studies. Do I think a decision to have a home birth all boils down to numbers? NO. But I believe they are important pieces to consider and women deserve to have the truth in order to make informed decisions. I am not "torturing the data" just because I am offering up mortality rates from other studies/sources for comparison because NONE were provided in the study.

I also never said hospitals were perfect and there aren't issues in the hospital system. If a woman is a good VBAC candidate, it sucks that she might not be able to find a willing provider in the hospital. It's AWFUL. I'm well aware that there are issues and horrible options for some women out there. BUT none of that excuses the fact that no comparison numbers were provided in this study. That's what we're talking about here. The mortality rates in this study.

You said "There is ZERO basis for your statements of “X babies will die that would have lived had they been under the care of a CNM at a birth center.”"

So I will write it out another way.

Again, these numbers reflect the LOW RISK women in these two studies:

TOTAL MORTALITY RATES for LOW RISK (intrapartum plus neonatal):

MANA study = 1.61/1000
Birth Center study = 0.87/1000

For every 1,000 babies born at home to a low risk mom, 1.61 will die; for every 1,000 babies born at a CABC accredited birth center to a low risk mom, 0.87 will die. This means for every 10,000 babies born at home to a low risk mom, 16.1 will die; for every 10,000 babies born at a CABC birth to a low risk mom, 8.7 babies will die. That's about twice as many babies that die at home... or an additional 7 babies per 10,000.

PermalinkSubmitted by Jeff Olejnik MD... (not verified) on February 2014

Anna, it is so funny how you defend the press release statement of MANA stating their are no increase in bad outcomes, when the data clearly shows an increase in risk. Especially in those high risk groups of HBAC, twins, and breech. Yet MANA offers no guidelines for Homebirth midwives to follow to help prevent bad outcomes based on these increase in bad outcomes. I find that horrendous. Even ACOG published yet another paper about preventing the first cesarean as a reminder to ACOG members to continue to follow previous recommendations. Yet on line Homebirth advocates like Penny Simkins are over reacting to the ACOG paper while they under react to their own data and don't even provide guidelines like ACOG does. MANA just prints the data, states there is no statistical difference to some and maybe some difference to others but go ahead and keep doing what you want. We don't need to force any safety guidelines on you. Even the Cornell paper came out with nearly the same increase bad outcomes as the MANA data, but you people still defend MANA. MANA tries to discredit the Cornell paper by complaining about birth certificate reliability, yet it's MANA who used birth certificate data to tell the world about the 26% rise in Homebirth over the last five years. And the Cornell paper used linked birth and death certificates to generate their data. How can so many agencies, data sets, and yes even bloggers know MANA is covering up their bad 20-30% self reported survey results, but MANA and a few supporters thatvdefend it must be right?

PermalinkSubmitted by Jeff Olejnik MD... (not verified) on February 2014

@Elias
The absolute safety of not using a child seat belt or driving home drunk has an overall safe absolute safety, but using a seat belt and driving sober has a safer relative safety. So should we ignore the increased risk this MANA "survey" demonstrates?

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